FORM 1-A-SCC

VERIFICATION AND CERTIFICATION OF

NON-FORUM SHOPPING

I, ______________________________________, of legal age,

(Name)
_____________________________ _____________, and a resident
(citizenship) (civil status)
of ____________________________________________________ ,
after having been duly sworn to in accordance with law, hereby,
depose and say:

1. That I am the _______________________ in the above-

entitled case and have caused this
______________________________ to be prepared; that I
read and understood its contents which are true and correct
of my own personal knowledge and/or based on authentic
records;

2. That I have not commenced any action or proceeding

involving the same issue in the Supreme Court, the Court of
Appeals or any other tribunal or agency; that to the best of
my knowledge, no such action or proceeding is pending in
the Supreme Court, the Court of Appeals or any other tribunal
or agency, and that, if I should learn thereafter that a similar
action or proceeding has been filed or is pending before
these courts or tribunal or agency, I undertake to report that
fact to the Court within five (5) days therefrom.

IN WITNESS WHEREOF, I have hereunto set my hand this

______ day of __________________, 20 __.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this ______ day of

_____________, 20 ___ .

NOTARY PUBLIC